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Declaration of Domicile and Citizenship
To TIIE STATE AND Ct7UNTY TAX ASSESSGR, E~I~I~ ~~ e~c~364
iT. LUCIE COUNTY, FLORIDA: ~T. ~'~~C ('^~:hT!'~ t~,A,
This is my declaration of Domicile ar-d Citizenship in the State of Florida that I am tiling this day In accordance
and in conformity with Chapter 222, Section 222.17, Florida Statutes.
-~~est Ohiaa~o Illinois _ _
I was formerly a legal resident of •
[City) State
30 W 66 Nren Lane
and I resided at
[Street end Number]
to and am and have been a bona fide resident o[ the State of Florida sincY
OCtOber 19-.52 and I reside at
290 N. Fed. Highway
[Street and Number]
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
and this state^;ent is to be taken as my declaration of citizensh lp, actual legal residence and domicile in the State of Florida.
[Insert here any pertinent facts, su^h as sal^ of property or business, or relinquishment of employment
at forme[ domicile, removal of family to new domicile pi:rchase of home, ete•)
Entering Presley iYood in 12 Grade
•1.109'0
.::,r-_.
.- :~ ~~vir. ~o -
::r~-.. -{J~
t f1 , : 7 C- ~,
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FILED AND RECORDED
(ti'~(a~~~-BOOK
1962 DEC -6 PM 2: 04
RAGER POITRAS, CIERK
ST. IUC;f COUNTY, FLOR~A~c~~~
I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and comply
with all other„;~irements of a legal resident of this State.
.•• .t=-~
~ ~~Y that I have no intention to return to my former domicile, and I intend to remain in
F'Oi~~ `~ ~ ` y ~'~~' yg,~ COUNTY, FLORIDA, permanently. ~
~ ~ - ;;~~^ t °. - - [Name]
f!?j ., ~ j'-.''~, . ~_G~,3-stn
•.;r~~(~~..,~; _ [Address)
~ r., • ,•`,~ .
...,.:,;,. ,. 8 Deaelnber - is 82
SK•orn to an$ subscribed before me tt+ta Say of --
P.OuER POITRAS --- ------- - -
CZERI{ CUIT COURT Notary Public
~~ `~ `
3y D.C. b2y Co-nmission expires
[To ba exocuted in duplicate and dri=Ina.l flied crlth Clerk Clrcult Cann, and duplicate wltb Tax Assessor]
Ho~cever, I have changed my domicile
31 day of